1985, 03-04 Permit App: 00004368 Furnace f
MECHANICAL PERMIT APPLICATION WORKSHEET
PLEASE PRINT AND COMPLETE ONLY THOSE PARTS OF THE FORM YOU UNDERSTAND
1 Owner's Name (Last) /� (First) (M) Department Use Only
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�� Project No.
2 Project Address(Not Mallin Address) Space Zip
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3 City/Community State Subdivision/Plat Name
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4 Assessor P cel No. Lot Block /368
16 Contractor Firm NameStreet dress
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17 Zip Cit State Phone
18 Contact Person License No. Phone If different than above
ALM-too !
a Owner/Agent(:f different than el above) I Business Address
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9 Zip City State Phone
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15 Describe Work:
New)' Addition/Alteration 0 Replace/Repair 0
10 Applicant Name Street Address
11 Zip City State Phone
( )
* *
8 VENT: Fan(s): Evap Cooler(s): Hood(s): Duct(s)1: Miscellaneous:
10 APPLIANCE: Wood Stove/
Dryer(s): I Range(s): Gas Log(s): Solid Fuel: Gas Water Heater(s):
Z 11 UNIT HEATER(S): Wall Mount: Y N Floor: Y N Suspended: Y N
W
a12 AIR HANDLING: 10,000 CFM or less: More than 10,000 CFM: •
5
0
W 13 REFRIG SYSTEM BTU: 1-100M: 100-500M: 500-1000M:
LL
0
W 14 1000-1750M: Other: • Pressure Vessel(cu.ft.):
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Z 15 COMPRESSOR/HP: Less than 3: 13-15: - 15-30: • 30-50: 50+:
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W 16 GAS PIPING SYSTEM:Number of outlets:
03
2
Z 17 HEATING SYSTEM:1-100,000 BTU: �"// (5:- /J f (A__, 100,001+BTU:
18 TYPE FUEL SOURCE: Electric J / Gas 0 ; Oil 0 ; Coal 0 ; Wood 0 ; Solar 0
19 TYPE DISTRIBUTION: Forced Air2t; Radiant 0 ; Heat Pump 0
.1* Number of separate zones for any heating, A/C or air handling system. 4Q•'
I certify-that the above information as submitted by me is true and correct and further, agree that all pro-
visions of laws and ordinances governing this type of work, including inspection requirements, will be com-
plied with whether specified herein or not. The granting of a permit does not presume to give authority to
violate or cancel the provisions of any state of local laws regulating construction or the performance of
• construction.
SIGNATURE OF /-`,, , , APPLICATION
OWNER OR c t__,,— -fie`co. DATE 3/Y/�S